TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER hh: WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY
PART 2905 REGISTRATION OF WORKERS' COMPENSATION UTILIZATION REVIEW ORGANIZATIONS
SECTION 2905.EXHIBIT A APPLICATION FOR REGISTRATION OF A UTILIZATION REVIEW ORGANIZATION



Section 2905.EXHIBIT A   Application for Registration of a Utilization Review Organization

 

1.

Name of Applicant

 

 

Type of Application (check one):

 

 

Corporation

 

Partnership

 

Limited Liability Corporation

 

Other (Describe)

 

 

FEIN

 

 

 

Contact Person

 

 

Business Telephone Number

(     )

 

 

Fax Number

(     )

 

 

Email Address

 

 

2.

Type of Utilization Review Organization (check all that apply):

 

Health Care Utilization Review (as defined in 50 Ill. Adm. Code 4520.30)

 

Workers' Compensation Review (as defined in Section 2905.10 of this Part)

 

Check all categories that apply (as applicable)

 

Licensed HMO providing utilization review services outside of the HMO (as defined in 50 Ill. Adm. Code 4521.20)

 

Licensed HMO providing utilization review services only within that HMO (as defined in 50 Ill. Adm. Code 4521.20)

 

Third Party Administrator

 

Licensed Insurance Company providing utilization review services outside of that Insurance Company

 

Licensed Insurance Company providing utilization review services only

within that Insurance Company

 

Hospital or Medical Group providing utilization review services for other than internal purposes

 

Workers' Compensation Utilization Review Organization

 

Other (Describe)

 

3.

Business Address

 

 

Street (do not use P.O. Box)

 

 

City

 

State

 

Zip

 

-

 

4.

Mailing Address

 

 

Street or P.O. Box

 

 

City

 

State

 

Zip

 

-

 

5.

Business Telephone Number

(     )

 

 

Toll Free Number

(     )

 

 

Fax Number

(     )

 

 

Email Address/Website

 

 

6.

Agent for Service of Process in Illinois

 

 

Name

 

 

Street (do not use P.O. Box

 

 

City

 

State

 

Zip

 

-

 

7.

For each Utilization Review Program supply the following information:

 

a)

The name, address, telephone number and normal business hours of the utilization review programs.

 

b)

The organization and governing structure of the utilization review programs.

 

c)

The number of reviews in Illinois for which utilization review is conducted by each utilization review program for the current year.

 

 

  Health Reviews

 

 

 

  Workers' Compensation Reviews

 

 

d)

Hours of operation of each utilization review program.

 

e)

Description of the grievance process for each utilization review program.

 

f)

Please check (all that apply) to determine if you are using the Health Standards and/or the Workers' Compensation Standards in order to meet or exceed American Accreditation Healthcare Commission (URAC) Standards and provide the Department with a copy of your current certificates, if applicable.

 

 

  Health Utilization Standards

 

 

  Workers' Compensation Standards

 

g)

Number of review in Illinois for which utilization review was conducted for the previous calendar year for each utilization review program.

 

 

  Health Reviews

 

 

 

  Workers' Compensation Reviews

 

 

h)

Written policies and procedures for protection of confidential information according to applicable State and Federal laws for each utilization review program.

 

i)

Biographical information for organization officers and directors.  Biographical affidavits shall be stamped "confidential" by the utilization review organization.

8.

Indicate accreditation status below:

 

a)

  Health accredited by:

 

 

  URAC (as defined in 50 Ill. Adm. Code 4520.130(b))

 

 

  NCQA (as defined in 50 Ill. Adm. Code 4520.130(b))

 

 

  JCAHO (as defined in 50 Ill. Adm. Code 4520.130(b))

 

 

  AAAHC (as defined in 50 Ill. Adm. Code 4520.130(b))

 

b)

Workers' compensation accredited under:

 

 

  URAC Health Standards

 

 

  URAC Workers' Compensation Standards

 

c)

  Unaccredited

9.

Check Enclosed

 

a)

Accredited fee $1500 biennially

 

b)

Unaccredited fee $3000 biennially

10.

Affirmation (to be signed by an officer or director of the utilization review organization only):

 

I,

 

do hereby certify that

 

 

(Typed name, title)

 

 

 

 

(Utilization Review Organization)

 

complies with the Health and/or Workers' Compensation Utilization Management Standards of the American Accreditation Healthcare Commission (URAC) sufficient to achieve American Accreditation Healthcare Commission (URAC) accreditation or submits evidence of accreditation by the American Accreditation Healthcare Commission (URAC) for its Health and/or Workers' Compensation Utilization Management Standards, and do hereby affirm that all of the information presented in this application is true and correct.

 

 

 

 

 

(Signature)

 

(Date)

 

Please mail completed application to:

 

Illinois Department of Insurance

Utilization Review Unit

320 West Washington Street

Springfield IL 62767-0001

(217) 558-2309

 

(Source:  Amended at 42 Ill. Reg. 20363, effective November 1, 2018)